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Regulating posttraumatic stress disorder symptoms with neurofeedback:

Regaining control of the mind

Article in Journal of Military Veteran and Family Health · March 2020

DOI: 10.3138/jmvfh.2019-0032

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 EMERGING PRACTICES AND
PROGRAMS
Regulating posttraumatic stress disorder symptoms with
neurofeedback: Regaining control of the mind
Andrew A. Nicholsona, Tomas Rosb, Rakesh Jetlyc and Ruth A. Laniusd
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh.2019-0032 - Saturday, March 21, 2020 4:20:46 PM - IP Address:213.182.207.12

ABSTRACT
Neurofeedback is emerging as a psychophysiological treatment where self-regulation is achieved through online feed­
back of neural states. Novel personalized medicine approaches are particularly important for the treatment of posttrau­
matic stress disorder (PTSD), as symptom presentation of the disorder, as well as responses to treatment, are highly het­
erogeneous. Learning to achieve control of specific neural substrates through neurofeedback has been shown to display
therapeutic evidence in patients with a wide variety of psychiatric disorders, including PTSD. This article outlines the
neural mechanisms underlying neurofeedback and examines converging evidence for the efficacy of neurofeedback as an
adjunctive treatment for PTSD via both electroencephalography (EEG) and real-time functional magnetic resonance
imaging (fMRI) modalities. Further, implications for the treatment of PTSD via neurofeedback in the military mem­
ber and Veteran population is examined.
Key words: amygdala in PTSD, brain wave oscillations, EEG neurofeedback, emotion regulation, fMRI
neurofeedback, military, NATO, neurofeedback, personalized medicine, PTSD, Veterans

RÉSUMÉ
Introduction : La rétroaction neurologique apparaît comme un traitement psychophysiologique qui permet l’autorégu­
lation par la rétroaction en ligne des états neuronaux. Méthodologie : Les nouvelles approches de médecine person­
nalisée sont particulièrement importantes pour le traitement du syndrome de stress post-traumatique (SSPT), car la
présentation des symptômes et les réponses au traitement sont hautement hétérogènes. Résultats : Il est démontré que le
fait d’apprendre à contrôler des substrats neuronaux précis grâce à la rétroaction neurologique donne des résultats théra­
peutiques chez des patients présentant un vaste éventail de troubles psychiatriques, y compris le SSPT. Discussion : Le
présent article souligne les mécanismes neuronaux sous-jacents à la rétroaction neurologique et examine des données con­
vergentes sur l’efficacité de la rétroaction neurologique comme traitement d’appoint au SSPT, à la fois par l’électroencéph­
alographie (ÉEG) et l’imagerie par résonance magnétique fonctionnelle (IRMf ). De plus, on y étudie les conséquences
de la rétroaction neurologique pour le traitement du SSPT dans la population de militaires et de vétérans.
Mots-clés : amygdale en cas de SSPT, médecine personnalisée, militaires, oscillations des ondes cérébrales, OTAN,
régulation émotionnelle, rétroaction neurologique, rétroaction neurologique par ÉEG, rétroaction neurologique par
IRMf, SSPT, vétérans

THE NEED FOR NOVEL ADJUNCTIVE
TREATMENTS AND PERSONALIZED
MEDICINE IN PTSD
Posttraumatic stress disorder (PTSD) is a debilitating
psychiatric disorder that can develop in the aftermath
of psychological trauma.1 The incidence of PTSD in
all public safety personnel rescue workers2 worldwide
is 10%. An alarming national study in Canada found
that 44% of public safety personnel screened posi-
tive for symptom clusters consistent with one or more
mental health disorders.3 Similarly, 13% of returning
Canadian Armed Forces personnel are diagnosed with

a Department of Psychological Research and Research Methods, University of Vienna, Vienna, Austria
b Neurology and Imaging of Cognition Lab, University of Geneva, Geneva, Switzerland
c Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Ottawa
d Department of Psychology, Western University, London, Ontario
Correspondence should be addressed to Andrew Nicholson at dr.andrewnicholson@gmail.com

© Her Majesty the Queen in Right of Canada, as represented by the Journal of Military, Veteran and Family Health 3
Minister of National Defence, 2020. 6(Suppl 1) 2020 doi:10.3138/jmvfh.2019-0032
 Nicholson et al
deployment-related mental disorders, including PTSD.4
In addition, a cross-sectional World Health Organi­
zation survey, conducted in 11 countries, found that
PTSD was associated with 20.2% of sexual assault cases.5
Currently, common treatments for PTSD consist of psy­
chotherapy, pharmacotherapy, or a combination thereof.
However, dropout rates from psychological therapies,
such as trauma-focused cognitive behavioural therapy
and eye movement desensitization, are an important
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consideration for the military and Veteran population,6,7
where a recent systematic review reported an average
dropout rate of one in three patients among Veterans.7
In community-based settings, only 56% of patients with
PTSD received a minimally adequate dose of psycho­
therapy.8 A cross-national meta-analysis study suggests
that psychotherapy is reported to be successful in only
about 60% of cases.9 Pharmacological treatment can also
be effective in PTSD, however, research suggests a sub­
stantial portion of patients (41%) fail to respond to this
type of intervention.10,11 Further, it has been suggested
that PTSD treatment models must extend beyond one-
size-fits-all conceptualizations and adopt a personalized
medicine approach to treatment if they are to adequately
reflect the evidence base and the complexity of PTSD in
Veteran populations.12
Importantly, neurofeedback with both electroen­
cephalography (EEG) and functional magnetic reso­
nance imaging (fMRI) represent an emerging adjunc­
tive treatment that allows patients to self-regulate neural
states. The underlying benefit of this treatment practice
is that one can directly entrain and regulate neural activ­
ity along with associated psychological symptoms.13–15
In a systematic review of biofeedback for psychiatric
disorders, 70% of the studies reported a statistically-
significant clinical improvement in the treatment of de­
pression or anxiety disorders.16 Furthermore, with regard
to patients with PTSD, a recent cross-national systemat­
ic review found that all 10 neurofeedback studies, which
included military members, demonstrated positive im­
provements on at least one PTSD symptom.17
Novel adjunctive treatments are particularly import­
ant for the treatment of PTSD, as it is a highly hetero­
geneous disorder, where symptom severity and the pre­
dominance of certain symptoms greatly differs between
individuals, especially in more chronic cases over time.1,18
Based on diagnostic criteria from the Diagnostic and Sta­
tistical Manual of Mental Disorders, 5th edition (DSM-5), a
classification manual used by mental health professionals,
there are more than 600,000 symptom combinations or
4 Journal of Military, Veteran and Family Health
doi:10.3138/jmvfh.2019-0032 6(Suppl 1) 2020
ways in which a person can present with PTSD.1,18 More­
over, a dissociative subtype of PTSD has been defined
in which individuals present with additional symptoms
of depersonalization and derealization, with associated
abnormal neural circuitry in emotion regulation and
fear-responding regions.1,19–22
Given the diversity of brain circuits that may be
involved in PTSD, modern neurofeedback technology
may facilitate a more personalized approach to medicine
when treating patients with PTSD and could also help
to improve symptoms in those individuals previously
resistant to treatment. The current review will focus on
the fMRI and EEG signals that are used for neurofeed­
back, together with studies that demonstrate converg­
ing neurobiological evidence for their use as treatments
in patients with PTSD.
INTRODUCTION TO NEUROFEEDBACK
Neurofeedback is non-invasive approach used in the
treatment of a wide range of neuropsychiatric disorders,
including PTSD.13,14,16–18,23 Many different neurofeed­
back protocols and methods exist, where treatment flex­
ibility may be particularly advantageous in PTSD, as it
is a heterogeneous disorder with a wide range of symp­
toms.1,18,19,22 Neurofeedback involves a brain-computer
interface that provides real-time feedback of brain ac­
tivity that individuals learn to regulate using a “closed­
loop” paradigm.13,14,24 Typically, the neural signal is fed
back to the person as an auditory or visual signal. The
individual receives positive feedback each time progress
is made toward normalizing aberrant neural activity.14,18
Clinicians are able to target specific neural dynamics
in the brain, related to PTSD symptom presentation
and maintenance, which allows patients to self-regulate
pathological states.18,25 Neurofeedback protocols can be
used with fMRI neuroimaging to precisely target local­
ized brain regions and related brain networks, whereas
EEG neurofeedback is used to regulate more global sig­
nals, indicative of large-scale brain oscillations.13,14 No­
tably, EEG neurofeedback has also recently been used to
target more specific subcortical regions of the brain.26–28
Neurofeedback represents a closed-loop design, mean­
ing continuous sensory representations of brain activity
are provided to individuals in real-time with the aim
of controlling this activity.13,14 Neurofeedback can be
conceptualized as a “virtual mirror for neural dynam­
ics occurring within the brain”, in which this interface
allows for the modification of such dynamics and their
corresponding psychological state(s).13

In terms of mechanisms, the direct causal pathways
that mediate neurofeedback are yet to be elucidated ful­
ly. However, several theories exist. Briefly, neurofeed­
back has been proposed to involve Hebbian plasticity,
homeostatic plasticity, and structural plasticity within
the brain.13,14,18,29 Neuroplasticity is a concept that is
widely supported by research within the field, in which
neurofeedback may not only alter the strength of neural
circuitry connections and activity within the synapse,
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh.2019-0032 - Saturday, March 21, 2020 4:20:46 PM - IP Address:213.182.207.12
but may also directly modulate abnormal brain oscilla­
tions.13,14,18 In support of structural changes occurring
in response to neurofeedback,30,31 a recent fMRI study
reported post-training microstructural changes with re­
gard to white matter pathways and grey matter volume
among areas involved in the sustained attention neuro­
feedback task.29 Finally, in support of homeostatic plas­
ticity, EEG neurofeedback has been shown to result in
a homeostatic rebound of brain wave oscillations, which
has been associated with the normalization of abnormal
brain circuitry in patients with PTSD and acute symp­
tom alleviation.32 In terms of implementing neurofeed­
back treatment interventions specifically in patients with
PTSD, several neurophysiological measures have been
identified, which represent key targets for modulation/
intervention via neurofeedback.
WHAT ARE THE NEURAL TARGETS FOR
MODULATION IN PTSD?
Intrinsic connectivity networks (ICNs) have been
shown to be particularly important for proper neural
functioning in humans. Specifically, the main ICNs
consist of the default mode network (DMN), central
executive network (CEN) and salience network (SN),
where dysfunction in these three core networks plays
a significant role in a broad range of psychopatholo­
gy.33 These ICNs have been shown to be abnormal in
PTSD and are hypothesized to be related to specific
symptom presentations within the disorder, including
altered self-referential processing and social cognition
(DMN),34,35 cognitive dysfunction (CEN),36–38 as well as
dysregulated arousal/hypervigilance and chronic threat
monitoring (SN).33,35,37,39–50 Neuroimaging studies in
PTSD suggest an over-engagement of the SN, failure
to properly recruit emotion regulation and executive
functioning areas within the CEN, and a breakdown of
functional connectivity within the DMN.45,51 Indeed,
neurofeedback has been proposed as a potential avenue
by which to normalize these network abnormalities in
PTSD.45
Regulating PTSD symptoms with neurofeedback
Recent studies suggest covariation between alpha-
wave oscillations in the brain and changes in the afore­
mentioned ICNs52,53 that are particularly implicated in
PTSD.45 Alpha oscillations (8–12Hz) are easily mea­
surable with EEG and correspond to a state of resting
wakefulness correlated to the DMN,54,55 where patients
with PTSD are known to display decreased DMN
connectivity at rest in key hubs of this network.40,45,46 In
conjunction, PTSD patients display abnormally reduced
alpha oscillations, proposed to be a global index of
chronic hyperarousal.13,56–58 Taken together, alpha-wave
oscillations are frequently a target for EEG neurofeed­
back due to their associations with symptoms of hyper-
arousal in patients with PTSD, along with their ability
to modulate autonomic activity related to the stress re­
sponse13 and ICN dynamics.32
Additionally, studies have repeatedly found that
PTSD is associated with less activation in the medial
prefrontal cortex (mPFC), which contributes to a loss of
top-down regulation on emotion generation areas such
as the amygdala, corresponding to PTSD symptoms of
hyperarousal vivid-reexperiencing, and emotion under-
modulation.19,20,22,59–69 PTSD symptoms of hyperarous­
al have been correlated with negative mPFC-amygdala
coupling,64 where PTSD patients display reduced PFC-
amygdala connectivity as compared to controls, cor­
responding to reduced regulation of emotion centres
during the resting state.70
Observations of these altered patterns of neural
functioning have driven efforts to develop novel treat­
ment interventions that target both large-scale neural
oscillations, as well as localized brain regions implicated
in PTSD symptomatology. Taken together, common
targets for treating PTSD via neurofeedback largely
consist of regulating directly abnormal alpha-based
brain oscillations related to ICNs, as well as directly reg­
ulating amygdala activation and associated top-down
recruitment/control from the mPFC.18,28,32,71,72 Inter­
estingly, empirical studies with fMRI and EEG neuro­
feedback signals evidence overlapping neurobiological
mechanisms, where both approaches have been shown
to lead to plastic changes in ICN and amygdala con­
nectivity. Specifically, real-time fMRI neurofeedback
targeting amygdala downregulation in PTSD patients
may lead to increased connectivity of the amygdala with
PFC emotion regulation areas as well as a plastic chang­
es within ICNs (DMN, CEN, and SN).71,72 Similarly,
alpha-based EEG neurofeedback also leads to plastic
changes within ICNs, with associated reductions in
Journal of Military, Veteran and Family Health 5
6(Suppl 1) 2020 doi:10.3138/jmvfh.2019-0032
 Nicholson et al
hyperarousal and a shift in amygdala connectivity away
from innate defence and fear-processing areas, toward
PFC emotion regulation areas.28,32 These converging
mechanisms underlying EEG and fMRI neurofeedback
are explored in the subsequent sections.
REAL-TIME fMRI NEUROFEEDBACK
IN PTSD
Real-time fMRI neurofeedback (rt-fMRI-nfb) involves
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh.2019-0032 - Saturday, March 21, 2020 4:20:46 PM - IP Address:213.182.207.12
learning to increase or decrease activity in specific corti­
cal or subcortical regions and has been used to modulate
neural correlates underlying psychopathology.14 Several
studies have examined the capacity to regulate emotion
processing by targeting neurofeedback of the amygdala
using rt-fMRI-nfb in both healthy individuals73–78 and
psychiatric populations, including borderline personal­
ity disorder (BPD),79 major depressive disorder,80–82 and
PTSD.71,72,83,84
The amygdala is a region associated with the pro­
cessing and generation of emotions,85–87 where dysregu­
lated amygdala activation has been shown to be central
to the development and maintenance of PTSD symp­
toms.19,22,46,51,67,68,88 Indeed, attenuated top-down regu­
lation from the mPFC with concomitant amygdala hy­
peractivity is a neural signature critical to symptoms of
emotion undermodulation (i.e., hyperemotionality), hy­
perarousal, and re-experiencing.19,20,22,46 Notably, direct
amygdala regulation via rt-fMRI-nfb has been shown to
also affect activation in PFC areas involved in emotion
regulation, as well as to enhance amygdala-PFC connec­
tivity.74–76,89 Neurofeedback regulation of the amygdala
may offer a way to therapeutically normalize the abnor­
mal cortico-subcortical pathways maintaining PTSD.
Nicholson et al.71 presented the first demonstration
of successful amygdala downregulation using rt-fMRI­
nfb in patients with PTSD. Here, patients were able to
downregulate both right and left amygdala activation
during a symptom provocation paradigm in which pa­
tients viewed words associated with their trauma.71 Im­
portantly, patients were also able to learn to regulate their
amygdala activation on a subsequent transfer trial with­
out neurofeedback.71 Here, increased activation in the
dorsolateral and ventrolateral PFC was observed in tri­
als where patients were instructed to downregulate their
amygdala.71 Interestingly, these regions are known to
be related to emotion regulation and executive func­
tioning, while their activation was negatively correlated
with PTSD symptoms during neurofeedback train­
ing.71 Furthermore, increased functional connectivity
6 Journal of Military, Veteran and Family Health
doi:10.3138/jmvfh.2019-0032 6(Suppl 1) 2020
between the amygdala and the PFC was found during
neurofeedback training. This study suggests that neuro­
feedback may be a therapeutic protocol for dampening
amygdala hyperactivity and restoring emotion regula­
tion PFC regions in patients with PTSD. These results
parallel other rt-fMRI-nfb studies in healthy individu­
als, where self-regulation of the amygdala, as compared
to control regions, was shown to increase activation in
emotion regulation PFC regions, as well as enhance
amygdala-PFC connectivity.74–76,89–91 Elsewhere, it has
also been shown that using rt-fMRI-nfb to enhance the
connectivity between the PFC and the amygdala during
threat exposure in highly anxious individuals resulted in
reduced anxiety in the absence of feedback.92
Finally, in terms of underlying mechanisms, an anal­
ysis exploring directional connectivity in a PTSD sample
including military members suggested that amygdala
downregulation involved both top-down and bottom-up
information flow with regard to observed PFC-amygdala
connectivity.71 These results support the hypothesis that
emotion regulation may be underpinned by a reciprocal
loop of information processing, in which information
flows in a bi-directional manner between the amygdala
and PFC during amygdala downregulating neurofeed­
back.14,71,92,94 Taken together, these studies suggest that
rt-fMRI-nfb may be an effective means of decreasing
amygdala hyperactivity and enhancing PFC activity/
connectivity in order to regulate emotion states. Inter­
estingly, increased PFC activation has also been reported
when examining neural activity, post-treatment, among
PTSD patients.11,88,95,96
In another Canadian research study, Nicholson
et al.72 also provided evidence that amygdala downreg­
ulation via rt-fMRI-nfb leads to plastic changes within
ICNs, which, as previously mentioned, represent neural
targets highly implicated in PTSD that are known to
be associated with symptom presentation.34,40,45,46,97 In
this study, that included military members with PTSD,
amygdala downregulation was associated with increased
recruitment of the left CEN over neurofeedback train­
ing runs, a finding supported by increased dorsolater­
al PFC activation during the downregulate condition,
specifically.72 Critically, the literature suggests decreased
recruitment and functional connectivity within CEN
emotion regulation PFC regions among PTSD pa­
tients,37,38,45,98 where attenuated regulatory activation in
the PFC is associated with PTSD symptoms of emotion
undermodulation (i.e., hyperemotionality) and amyg­
dala hyperactivation.19,20,22 This neurofeedback protocol

may represent a therapeutic strategy to restore activity
in emotion regulation regions within the CEN in an
attempt to counterbalance severe emotion undermod­
ulation that is observed in PTSD.72 In the same study,
DMN recruitment related to self-referential processing
and autobiographical memory was stabilized during
neurofeedback runs.72 Individuals with PTSD have been
shown to maladaptively recruit the DMN during tasks
that require cognitive control.97 Hence, stabilization of
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the DMN may represent a normalization of neural dy­
namics within this network; that is, a decrease from the
response typically observed in PTSD patients.72 This nor­
malization may allow patients to increase recruitment
of the CEN involved in executive regulation, resulting
in more control over emotion generation centres in the
brain (e.g., amygdala). Taken together, these recent stud­
ies71,72 provide exciting, preliminary evidence that fMRI
neurofeedback involving downregulation of the amyg­
dala in PTSD is associated with measurable changes in
ICNs and emotion regulation regions,71,72 effects similar
to those observed using EEG signals for neurofeedback
in patients with PTSD.28,32
EEG NEUROFEEDBACK IN PTSD
EEG neurofeedback consists of regulating electro­
cortical oscillations in real-time, also known as brain
waves. Historically, the EEG signal was the first to be
used for neurofeedback in order to regulate neural ac­
tivity and corresponding pathological brain states in
patients with PTSD, 28,32,99–101 culminating in a recent
randomized controlled trial in patients with chronic
PTSD.102
Peniston and Kulkosky100 reported one of the first
studies that demonstrated significant reductions in
PTSD symptoms following the regulation of alpha
brain waves using EEG neurofeedback in Veterans with
PTSD. After training to increase “slow” brain waves
(i.e., alpha and theta waves), only 20% of PTSD patients
had a recurrence of PTSD symptoms over a 30-month
period, consisting of monthly follow-up assessments, in
contrast to 100% of the control group.100 Furthermore,
the neurofeedback group also displayed more significant
improvements on the Minnesota Multiphasic Personal­
ity Inventory (MMPI) scales, as compared to controls.99
More recently, a mechanistic study on alpha-based neu­
rofeedback in PTSD patients was found to rescue alpha
oscillations post-training, which was directly associated
with significant reductions in hyperarousal symptoms.32
Interestingly, this neurofeedback protocol also lead to
Regulating PTSD symptoms with neurofeedback
changes in ICNs highly associated with PTSD symp­
tomatology.32,45 This included plastic modulation of the
DMN involved in PTSD alterations in self-referential
processing and autobiographical memory, as well as al­
terations within the SN involved in the detection of sa­
lient threat in the environment and hypervigilance.32,45
Notably, this was the first study to show that key brain
networks underpinning PTSD can be volitionally mod­
ulated by EEG neurofeedback with outcomes on im­
mediate symptomatology.32 Importantly, these results
are supported by other alpha-based, controlled neuro­
feedback studies in healthy individuals, which display
lasting changes in cortical plasticity post neurofeed­
back.103,104
Relevant to EEG neurofeedback targeting hyper-
arousal symptoms in patients with PTSD, a subsequent
study from a Canadian laboratory aimed to investigate
amygdala functional connectivity before versus after
treatment with alpha-based neurofeedback.28 Here, pri­
or to neurofeedback treatment, PTSD patients displayed
stronger amygdala connectivity to areas implicated in
threat, emotion, and fear processing, as well as trauma
memory retrieval areas (brainstem periaqueductal gray
and hippocampus, respectively). Interestingly, after a
30-minute session of alpha-based EEG neurofeedback,
the amygdala shifted connectivity to PFC emotion
regulation areas involved in top-down executive func­
tioning. 28 This switch in amygdala connectivity was
positively associated with reduced hyperarousal among
patients and negatively correlated to PTSD symptom
severity. In a wider context, the results were consistent
with neurocognitive models of PTSD emotion under-
modulation, which suggest that PTSD symptoms man­
ifest from weakened top-down cortical regulation of the
subcortically hyperactive amygdala and limbic system.22
Critically, this study represents a therapeutic “tuning”
of neural dynamics toward increased top-down regula­
tion over the limbic (amygdala) and midbrain (periaq­
ueductal grey) systems with associated acute symptom
alleviation.28,105
In accordance with this model, EEG neurofeed­
back training of amygdala-correlated activity leads to
emotion regulation improvements in soldiers during
combat training.26 Taken together, EEG neurofeedback
represents a non-invasive way to normalize dysregulat­
ed activation in emotion regulation areas of the PFC, as
well as in limbic and midbrain brain structures involved
in innate fear and reflexive responding to trauma (amyg­
dala and brainstem periaqueductal grey), with the aim
Journal of Military, Veteran and Family Health 7
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 Nicholson et al
to correct neural patterns of emotion undermodulation
in PTSD.28
In support of this, a recent randomized control tri­
al on alpha-based EEG neurofeedback in patients with
chronic PTSD showed that, as compared to the control
group, neurofeedback treatment produced significant
improvements for both PTSD symptoms and capacity
for emotion regulation.102 Neurofeedback led to sig­
nificant reductions in the number of patients meeting
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criteria for PTSD — from 88.9% to 27.3% in the exper­
imental neurofeedback group — that was sustained in a
one-month post-treatment follow-up.102 Participants in
this study consisted of a number of traumatized indi­
viduals with PTSD who had not responded to at least
six months of trauma-focused psychotherapy.102 Only
a very small amount (4%) of participants in the active
treatment condition reported side effects of increased
flashbacks,102 although additional research is needed to
elucidate further potential side effects of neurofeedback
in trauma samples. Another study demonstrated that 30
sessions of alpha-based EEG neurofeedback lead to in­
creased cognitive functioning and decreased symptoms
of depression among PTSD patients.101 Notably, where­
as most evidence-based therapies for PTSD focus on
the processing of trauma memories, the target of neuro­
feedback is neural regulation, stabilization, and homeo­
stasis. Since cognitive self-regulation disruptions have
been identified as an obstacle for psychotherapy-based
treatments, neurofeedback may be especially beneficial
for PTSD patients who are highly anxious, dissociated
or dysregulated, and who may not tolerate or respond
to other forms of treatments.22,102,106 Taken together,
empirical evidence for both EEG and fMRI neurofeed­
back modalities suggest that modern neurofeedback
technology may facilitate a more personalized medicine
approach when treating patients with PTSD and may
utilize similar neural mechanisms/pathways to achieve
these therapeutic results.
CONVERGING EVIDENCE FOR REAL-TIME
fMRI AND EEG NEUROFEEDBACK IN THE
TREATMENT OF PTSD
Interestingly, both f MRI and EEG modalities
demonstrate very similar neurobiological mechanisms
in terms of normalizing disrupted brain circuitry in
PTSD. Both amygdala-targeted rt-fMRI-nfb71,72 and
alpha-based EEG neurofeedback 28,32 lead to (1) plas­
tic modulation of ICNs associated with PTSD symp­
tom presentation; (2) functional changes in amygdala
8 Journal of Military, Veteran and Family Health
doi:10.3138/jmvfh.2019-0032 6(Suppl 1) 2020
connectivity; and (3) increased PFC activation and
functional connectivity to key limbic structures indic­
ative of increased top-down control of emotion gener­
ation regions (Figure 1). In addition, neurofeedback
appears to shift amygdala functional connectivity away
from fear-processing and defence regions and towards
emotion regulation regions, an effect which is negative­
ly correlated to PTSD symptoms and alpha rhythm,
and is associated with increased calmness among PTSD
patients. 28,32,71,72
Relevant for the implementation of neurofeed­
back locally in the clinic and remotely among deployed
military members, EEG neurofeedback is a relatively
inexpensive and mobile tool for administering neu­
rofeedback. Furthermore, EEG-based neurofeedback
treatment settings are arguably more comfortable envi­
ronments than the fMRI scanner. Nonetheless, fMRI
studies are also important for investigating anatom­
ically localized neural mechanisms underlying neu­
rofeedback. Hence, a convergence of EEG and fMRI
neurofeedback modalities are critical for the clinical
integration of neurofeedback for PTSD treatment. In­
deed, scientists in the field of neurofeedback have begun
to use simultaneous EEG/fMRI recordings to define
patterns of electrical recording that correlate to highly
specific subcortical targets normally only measurable
with fMRI.26,27 Importantly, when targeting the amyg­
dala via EEG neurofeedback, results suggest modulation
of neural pathways comodulated during amygdala-based
targeted rt-fMRI-nfb.26,27 Furthermore, correlations be­
tween amygdala fMRI activity and frontal EEG asym­
metry during amygdala-based rt-fMRI-nfb training in
patients with depression also suggests that EEG and
fMRI-based neurofeedback methods have overlapping
mechanisms of modulation.81 Specifically, the study by
Zotev et al.81 suggests that EEG-based neurofeedback
on frontal EEG asymmetry in the alpha band may be
compatible with amygdala-based targeted rt-fMRI-nfb.
It has also been suggested that a combination of the two
methods could enhance emotion regulation training in
patients with other psychiatric disorders.81
In terms of future directions, multiple researchers
in Ruth Lanius’ laboratory are analyzing a 20-session
randomized controlled trial of alpha-based EEG neu­
rofeedback in patients with PTSD to compare against
sham neurofeedback and healthy controls. fMRI data
collected throughout the clinical trial will also be an­
alyzed to elucidate further specific neural mechanisms
related to changes in symptomatology. In this study,
 Regulating PTSD symptoms with neurofeedback
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Figure 1. Converging evidence for neurobiological mechanisms underlying both EEG and real-time fMRI neurofeedback
Solid red lines indicate increased functional connectivity, while broken red lines indicate decreased connectivity between
brain regions. Alpha-based EEG neurofeedback that targets abnormal cortical oscillations leads to a shift in amygdala
connectivity toward emotion regulation areas and away from threat, fear, and defence processing regions, as well as areas
implicated in trauma memory. Decreased DMN activity during EEG neurofeedback is associated with a homeostatic
normalization of such activity, with increased SN connectivity and decreased hyperarousal in PTSD patients. Amygdala-
based real-time fMRI neurofeedback that targets a localized brain region highly implicated in PTSD emotional responses,
which similarly involves increased amygdala connectivity to, and activation within, emotion regulation areas. Furthermore,
downregulating the amygdala in PTSD patients is associated with increased CEN and SN recruitment as well as normalized
DMN recruitment. In sum, both modalities of neurofeedback lead to a reorganization of amygdala functional connections, in
addition to increased emotion regulation activity and plastic modulation of ICNs.
EEG = electroencephalography; DMN = default mode network; SN = salience network; CEN = central executive network;
ICN = intrinsic connectivity network; PTSD = posttraumatic stress disorder.

it will also be critical to examine PTSD heterogeneity,
and unique responses to treatment among PTSD and its
dissociative subtype.1,19–22
In summary, observations of altered patterns of
neural functioning within PTSD patients have driven
efforts to develop novel treatment interventions that
target both abnormal brain oscillations and localized
anatomical brain regions. Both fMRI and EEG neuro-
feedback modalities display common evidence for un­
derlying neurobiological mechanisms, where both have
been shown to lead to plastic changes in ICNs, as well
as changes in emotion regulation regions and amygda-
la connectivity. In conclusion, PTSD is a debilitating
disorder with complex symptomatology and psychopa-
thology, as well as a high degree of comorbidity. Among
military members and the Veteran population in Can-
ada, it is clear that PTSD can be difficult to treat and
that current therapies are not always effective for all
patients. Growing evidence suggests neurofeedback rep-
resents a novel adjunctive treatment for PTSD, in addi-
tion to a wide range of other psychiatric disorders.13,18
In light of the promising studies reviewed in this arti-
cle, neurofeedback offers a novel way to retrain brain
circuits under physiologically normal conditions, with
associated reductions in symptoms. As such, there is an
urgent need for further investigation of neurofeedback
in order to fully validate and define the neural mecha-
nisms underlying the therapeutic effect for PTSD. The
result of such scientific efforts could lead to a frontline,
non-invasive and modern method for treating PTSD
and related psychiatric disorders, for military personnel
and Veterans.
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AUTHOR INFORMATION
Andrew A. Nicholson, PhD, completed his studies in
neuroscience at the Schulich School of Medicine and
Dentistry at the University of Western Ontario. His research
background includes a multitude of brain imaging studies in
the field of psychiatric medicine, with expertise in a range of
technical brain imaging methods, including real-time fMRI
neurofeedback, dynamic causal modelling, and machine
learning.
Tomas Ros, PhD, is a neuroscientist investigating EEG-
based neurofeedback for the treatment of psychiatric

disorders such as PTSD and ADHD. He is currently based
at the University of Geneva, Switzerland.
Rakesh Jetly, MD, FRCPC, is Senior Psychiatrist and Mental
Health Advisor, Canadian Armed Forces, Ottawa. He is an
Associate Professor of Psychiatry at Dalhousie University and
at the University of Ottawa. He is also the Chair for Military
Mental Health with the Royal’s Institute of Mental Health
Research in Ottawa. He is committed to evolving mental
health research by investigating the biological underpinnings
of mental health disease, by incorporating technology to
https://jmvfh.utpjournals.press/doi/pdf/10.3138/jmvfh.2019-0032 - Saturday, March 21, 2020 4:20:46 PM - IP Address:213.182.207.12
modernize treatment and diagnostic modalities, and by
finding strategies to advance precision medicine.
Ruth A. Lanius, MD, PhD, is the director of the post­
traumatic stress disorder (PTSD) research unit at the
University of Western Ontario. She established the
Traumatic Stress Service and the Traumatic Stress Service
Workplace Program, which are services that specialize in
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Regulating PTSD symptoms with neurofeedback
the treatment and research of posttraumatic stress disorder
(PTSD) and related comorbid disorders. She currently holds
the Harris-Woodman Chair in Mind-Body Medicine at the
Schulich School of Medicine & Dentistry at the University
of Western Ontario.
COMPETING INTERESTS
None declared.
This article has been peer reviewed.
CONTRIBUTORS
All authors contributed to the manuscript and approved the
final version submitted for publication.
FUNDING
None declared.
Journal of Military, Veteran and Family Health 15
6(Suppl 1) 2020 doi:10.3138/jmvfh.2019-0032